OPEN ACCESS | Research Report | Published Online:10^th  December 2024                                                                             

CODEPENDENCY AND PERSONALITY CHARACTERISTICS OF CAREGIVERS OF PATIENTS WITH ALCOHOL DEPENDENCE SYNDROME: A CROSS-SECTIONAL STUDY 

                                                                                                                                                                                                                  

Alka Baby^1*, Geomy G Chakkalakudy², Neethi Valsan³, Joe Jose⁴

1. Consultant Psychiatrist 4. Consultant Paediatrician, St. Vincent De Paul Hospital Ollur, Thrissur, Kerala
2. Associate Professor, 3. Professor and Head, Department of Psychiatry, Jubilee Mission Medical College, Thrissur, Kerala

*Corresponding Author: Consultant Psychiatrist, St. Vincent De Paul Hospital Ollur, Thrissur, Kerala.

Email: akkibaby14@gmail.com

 

INTRODUCTION

Alcohol can have negative effects on a variety of factors, including health and social life, both immediately and over time. Alcohol Dependence Syndrome (ADS) is referred to as a family disease, as it can impact the entire family.¹ Each member of the family may be impacted in different ways. When a person with ADS concentrates primarily on obtaining and consuming alcohol, relationships are frequently put to the test.²

The spouse’s emotional and physical illnesses may worsen as a result of their partner’s alcohol use, which may also change how the family functions.³ Relationships with persons who have ADS can lead to codependency, which is an unhealthy preoccupation with the needs of the other person above one's own.^{4, 5} According to Dear et.al., codependency involves focusing on others' behaviors, neglecting one's own needs, trying to control others, and suppressing emotions, with the external focus being the most common trait.⁶

Codependency is a sort of dysfunctional relationship in which one person's self-worth and emotional needs are dependent on the other. Codependent family members of persons with ADS attempt to conceal the issue

to preserve the family's reputation and provide only positive pictures. They may unintentionally turn into enablers by lying to their ADS partners and encouraging them to keep drinking.

Similar patterns of co-dependent behaviors are seen in caregivers of individuals with mental health disorders and chronic illness, child rearing in dysfunctional families, and childhood abuse survivors.⁷ In any case, the primary characteristic of codependency is one partner giving the other excessive attention while disregarding his or her value. They frequently support each other by putting up with their misbehavior, giving up their happiness, and making adjustments.

Psychologists define personality as a unique blend of thinking, attitude, and behavior that emerges in childhood and endures over time.^{8, 9} Major research models investigating the impact of personality traits on stress reveal that personality shapes how individuals approach and encounter stress and influence their perceptions, evaluations, coping strategies, and responses to stressful situations.^10-13 Given this evidence, it seems plausible to suggest that the experience of living with an ADS partner likely varies among women, influenced by their individual personality traits.

ADS and codependency are two sides of a dysfunctional relationship that can reinforce each other.¹⁴ There are only limited studies exploring the codependent behavior in caregivers of ADS. Codependency can damage the family dynamics, so it is necessary to evaluate the caregiver’s behavior towards their ADS partners. It may be crucial to determine what a codependent relationship is, what it means for each person involved, and how to identify it. To strengthen the relationship, teaching them healthier coping skills is necessary. Codependent individuals can benefit from treatment by raising their self-esteem, which will enable them to prioritize their own needs and create healthier relationships.¹⁵ Just as this behavior can be learned, it can also be changed through treatment. Thus, this study evaluated the codependency and personality traits in caregivers of ADS patients and assessed the relationship between these two.

MATERIALS AND METHODS

This cross-sectional study was done at a tertiary care center in Thrissur, Kerala. The study was started after approval from the Institutional Ethics Committee (07/21/IEC/JMMC&RI). The study duration was 18 months (January 2021- August 2022). The sample size was calculated using n=Z (1-α/2)²× (p× q)/d² [Z (1-α/2) = 95% confidence level; p = Estimated proportion, q= (1-p), and d= 20% of p – allowable error]. Based on the proportion of codependency observed, which was 81% in an earlier similar study by Padmavathi et al.¹⁴, with a 95% confidence level and 5% relative allowable error, the minimum sample size comes to 73.

ADS patients were diagnosed using ICD 10 diagnostic criteria for research (DCR).  The caregivers of these ADS patients, who had provided informed written consent and were within the age group 20-65 years, were included in this study. It included the wives of patients and the mothers of unmarried patients. Only wives who have lived with the ADS spouse for at least two years were included. Those caregivers with learning disabilities and mental retardation, as well as caregivers with a history of mental illness, were not included in the study. An interview with a consultant psychiatrist at this institute confirmed this.

A specially designed proforma was used to collect socio-demographic details. The Spann-Fischer codependency Scale (SFCS)¹⁶, a 16-item self-report instrument, was used to assess codependency scores, rated on a 6-point Likert scale and summed to describe codependency from 16 to 96. The mean score is 52.6, with 67.2 considered "high" and 37.3 "low".¹⁶ The International Personality Disorder Examination (IPDE), a semi-structured clinical interview, assessed caregivers' personality characteristics according to ICD-10 and Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) classification systems. Developed by WHO and the US Alcohol, Drug Abuse, and Mental Health Administration, it includes a 59-item screening questionnaire with true or false responses.

The questionnaires were translated into Malayalam, back-translated to English, validated, and then used. The data collected was entered into Microsoft Excel and coded. Statistical analysis was performed using the IBM Statistical Package for Social Sciences (SPSS) Version 25. Numerical variables were expressed as mean and standard deviation and categorical variables as frequency and percentages. To find the association between codependency and personality traits of caregivers, Fisher's exact test was used. The statistical significance was assumed as p-value <0.05.

RESULTS

The study population consisted of 92 caregivers of patients with ADS. The majority of ADS patients belonged to the age group 31- 50 years, contributing about 52 (56.6 %) of total patients,22 (23.9%) of patients belonged to the age group 51-60,11(12%) of patients belong to age less than 30. Only seven (7.6%) of patients were older than 60.

Among the participants, 92 caregivers, 25 (27.2%) were mothers of the patient, and 67 (72.8 %) were wives of the patients. Among 92 caregivers, 27 (29.35%) belonged to the age group less than 40,55 (59.78%) caregivers belonged to the 40-60 age group, and only 10 (10.87%) caregivers belonged to the more than 60 age group. Fifty-five (59.8%) of caregivers had less than high school education, 21 (22.8%) of them were educated above post-secondary education, and 16 (17.4 %) had high school education. Seventy-four (80.4%) of caregivers were unemployed, and 18 (19.6%) were employed.  The socio-demographic variables of caregivers are shown below. (Table 1)

 

Table 1: Socio-demographic data of caregivers

Variables	Frequency (N=92)	Percentage (%)
Age of caregiver
≤40	27	29.35
40-60	55	59.78
>60	10	10.87
Education
Less than high school	55	59.8
High school	16	17.4
Secondary education	21	22.8
Occupation
Unemployed	74	80.4
Employed	18	19.6
Income
Nil	72	78.3
≤10000	9	9.8
≤25000	8	8.7
>25000	3	3.3

 

When the codependency scores were assessed among 92 caregivers, 53 (57.61 %) had low Spann Fischer codependency scores, 27 (29.35%) had moderate scores, and 12 (13.04%) had severe scores. When personality traits were assessed among the 92 caregivers, most had dependent personality traits, i.e., 28 (30.4%), followed by anxious traits with 27 (29.3%). None had paranoid, schizoid, or dissocial traits. (Table 2)

 

Table 2: Codependency scores and Personality traits of caregivers

Variables	Frequency (N=92)	Percentage %
Codependency scores
Low	53	57.61
Moderate	27	29.35
Severe	12	13.04
Personality traits
Dependent	28	30.4
Anxious	27	29.3
Borderline	23	25.0
Histrionic	9	9.8
Impulsive	3	3.3
Anankastic	2	2.2

 

Among 25 mothers of patients, 6 (24 %) were severely codependent caregivers, and among 67 wives of patients, 41(61.2%) were of low codependent scores. No statistically significant association was found between the codependency score and the relationship between caregivers and ADS patients. (Table 3)

 

Table 3: Association between Codependency scores and Relationship of Caregivers with ADS patients

Relationship	Codependency scores						p Value
	Low		Moderate		Severe
	N	%	n	%	n	%
Mother (n=25)	12	48.0	7	28.0	6	24.0	0.15
Wife (n=67)	41	61.2	20	29.9	6	9.0

 

No association was observed between socio-demographic variables of caregivers (age, education, occupation, income) and codependency score. (Table 4)

Table 4: Association between Socio-demographic variables of caregivers and codependency scores

Variables	Codependency scores
	Low		Moderate		Severe		p Value
	N	%	n	%	n	%
Age
≤40	20	74.1	5	18.5	2	7.4	0.17
40-60	30	54.5	17	30.9	8	14.5
>60	3	30.0	5	50.0	2	20.0
Education
Less than high school	27	49.1	18	32.7	10	18.2	0.17
High school	10	62.5	4	25.0	2	12.5
Secondary education	16	76.2	5	23.8	0	0.0
Occupation
Unemployed	41	55.4	22	29.7	11	14.9	0.52
Employed	12	66.7	5	27.8	1	5.6

 

A significant association was found between personality traits and codependency scores with a p-value <0.001. (Table 5) Seven (58.3%) and five (41.7%) of severely codependent caregivers showed dependent and anxious traits on IPDE, respectively. Severely codependent scores are seen only in these two personality traits. Twenty-one (39.6 %) of caregivers with low scores on SFCS had borderline traits. Sixteen (59.3%) of moderately codependent caregivers showed Dependent traits on IPDE. Seven (25.9%) of moderately codependent scores are seen in caregivers with anxious traits.

Table 5- Association between codependency score and personality traits

Personality traits	Codependency score						p Value
	Low		Moderate		Severe
	N	%	n	%	n	%
Anxious (n=27)	15	28.3	7	25.9	5	41.7	<0.001
Dependent (n=28)	5	9.4	16	59.3	7	58.3
Histrionic (n=9)	8	15.1	1	3.7	0	0.0
Impulsive (n=3)	3	5.7	0	0.0	0	0.0
Borderline (n=23)	21	39.6	2	7.4	0	0.0
Anankastic(n=2)	1	1.9	1	3.7	0	0.0

 

DISCUSSION

The study sample consisted of wives and mothers of 92 patients with ADS who were admitted to our hospital. Among the participants with ADS, 73.9% were married, 22.8% were single, and 3.3% were divorced. This contrasts with earlier findings that suggest married status serves as a barrier against the development of alcohol dependence.^17,18 However, several other studies indicate a significant correlation between married status and alcohol intake.^19-24

The present study observed that most caregivers (57%) of ADS patients had low codependency scores. It might be because the caregivers who participated in this study are more literate, have better-coping mechanisms, and have stronger support systems.^25,26 When it was compared with another study by Neena and Kishore ¹⁷, it was observed that 48% of the caregivers (wives) of alcohol-dependent patients were highly codependent. A similar observation was seen in another study conducted in Punjab, which showed that 72.2% had a medium level of codependency.¹⁸

When social-demographic variables like age, occupation, monthly family income, number of years of marriage, and number of children were compared in a previous study, it was found to be associated with the level of codependency.²⁴ Another study done in Maharashtra to assess codependency showed 52% of wives to be moderately codependent, and 48% were found to be highly codependent. Also, there was a significant correlation found between codependency and demographic variables like age, number of children, type of family, duration of married life, duration of alcohol consumption by husband, and alcoholic history in parents.²⁷ But the current study didn’t reveal any association between codependency and socio-demographic variables like age, education, occupation, and relationship status of caregivers with the patient. This could be due to the depressive symptoms associated with caregivers in the referenced studies and has focused on different caregiver populations, resulting in varied findings.

In the current study, 30.4% of caregivers of ADS patients have dependent personality traits, with anxious traits coming next with 29.3%. However, a previous study conducted by Rao et al. assessing personality characteristics of wives of alcoholics when compared with the wives of normal controls matched on socio-demographic variables suggests that there are no statistically significant differences between the two groups.²⁸ It may probably be because of the different assessment strategies used. In a study using the Minnesota Multiphasic Personality Inventory (MMPI) test, Avila et al. found that wives of alcoholic patients tend to be passive, dependent, and insecure.²⁹ These results were similar to the current study's findings. The SFCS scores and personality traits were significantly associated with this study, with a p-value of <0.001. Using the Eysenck Personality Inventory (EPI), Orford et al. found comparable findings to the current study, which demonstrated higher neuroticism (anxiety) ratings in spouses when compared to the general population control group.³⁰ Similar findings were drawn from Stanley's study, which was published in the Indian Journal of Social Work in 2004. It showed that codependents are likely to have poorer self-esteem and higher degrees of pessimism and neuroticism. The dysfunctional personality features found in these wives can be attributed to the stressful and compromised home environment seen in alcohol-complicated marriages. ³¹ Similar results were also found in a study by Panaghi L. et al., the scores for codependency among the wives of addicted males were much higher. The study also found that codependency is significantly affected by the combination of being an addict's spouse and several personality qualities like neuroticism, openness, and agreeableness.³²

This is a hospital-based study, not a community-based one. Hence the results cannot be generalized.   A longitudinal study with a large sample size would be more essential than a cross-sectional study, as coping methods can change over time and can influenced by factors like duration of marriage and alcohol consumption.

CONCLUSION

This study aimed to evaluate codependency in caregivers of patients with ADS and to examine the relationship between codependency and personality traits among these female caregivers. The findings highlight the association between codependency and personality traits of caregivers. Although this study revealed only a low percentage of severe codependency scores among caregivers, it is important to examine the partners of ADS patients for the development of codependency. In the future, identifying caregivers with codependency and providing appropriate treatments and assistance can significantly improve their self-esteem and quality of life.

REFERENCE

1. McCrady BS, Flanagan JC. The role of the family in alcohol use disorder recovery for adults. Alcohol Res. 2021;41(1):06. DOI: 10.35946/arcr.v41.1.06
2. Bhowmick P, Tripathi BM, Jhingan HP, Pandey RM. Social support, coping resources, and codependence in spouses of individuals with alcohol and drug dependence. Indian J Psychiatry. 2001;43(3):219-24. PMCID: PMC2956145
3. Tempier R, Boyer R, Lambert J, Mosier K, Duncan CR. Psychological distress among female spouses of male at-risk drinkers. Alcohol. 2006;40(1):41-9. DOI: 10.1016/j.alcohol.2006.09.032
4. Jack DC. Silencing the self: Women and depression. Cambridge (MA): Harvard University Press; 1991. [Google scholar]
5. O'Brien PE, Gaborit M. Codependency: a disorder separate from chemical dependency. J Clin Psychol. 1992;48(1):129-36. DOI: 10.1002/1097-4679(199201)48:1<129::aid-jclp2270480118>3.0.co;2-c
6. Dear GE, Roberts CM, Lange L. Defining codependency: A thematic analysis of published definitions. Adv Psychol Res. 2005. [Google Scholar]
7. Knapek E, Kuritárné Szabó I. The concept, the symptoms, and the etiological factors of codependency. Psychiatr Hung. 2014;29(1):56-64. PMID: 24670293
8. Barenbaum NB, Winter DG. Personality. In: Freedheim DK, editor. Handbook of psychology: History of psychology. Vol. 1. Hoboken (NJ): John Wiley & Sons, Inc.; 2003. p. 177–203. DOI: 10.1002/0471264385.wei0109
9. Caspi A, Roberts BW, Shiner RL. Personality development: stability and change. Annu Rev Psychol. 2005; 56:453-84. DOI: 10.1146/annurev.psych.55.090902.141913
10. Schneider TR. The role of neuroticism on psychological and physiological stress responses. J Exp Soc Psychol. 2004;40(6):795-804. DOI: 10.1016/j.jesp.2004.04.005
11. Engelhard IM, van den Hout MA, Kindt M. The relationship between neuroticism, pre-traumatic stress, and post-traumatic stress: a prospective study. Pers Individ Dif. 2003;35(2):381-8. DOI: 10.1016/S0191-8869(02)00200-3
12. Bolger N, Zuckerman A. A framework for studying personality in the stress process. J Pers Soc Psychol. 1995;69(5):890-902. DOI: 10.1037/0022-3514.69.5.890
13. Gunthert KC, Cohen LH, Armeli S. The role of neuroticism in daily stress and coping. J Pers Soc Psychol. 1999;77(5):1087-100. DOI: 10.1037//0022-3514.77.5.1087
14. Padmavathi P, Jemila I, Devi J, Maragatham M, Suganya S, Prakash V. Co-dependency and depressive symptoms among wives of alcoholics selected in hospital, Erode. Int J Adv Nurs Manage. 2014;2(3):143-6. [IJANM]
15. Lee KS, Shin SE, Park JE. The factors affecting codependence and relationship with how to cope with patient in the family of alcoholics. Eur Neuropsychopharmacol. 2007;17. DOI:10.1016/S0924-977X(07)70836-2
16. Fischer JL, Spann L. Measuring codependency. Alcohol Treat Q. 1991;8(1):87-100. DOI: 10.1300/J020V08N01_06
17. Loranger AM. International Personality Disorder Examination (IPDE). In: Loranger AM, Janca A, Sartorius N, editors. Assessment and diagnosis of personality disorders. Cambridge: Cambridge University Press; 1997. p. 43–51. [WHO Link]
18. Leonard KE, Rothbard JC. Alcohol and the marriage effect. J Stud Alcohol Suppl. 1999; 13:139-46. DOI: 10.15288/jsas.1999.s13.139
19. Plant M, Miller P, Plant M, et al. Marriage, cohabitation, and alcohol consumption in young adults: an international exploration. J Subst Use. 2008; 13:83-98. DOI:10.1080/14659890701820028
20. Schoenborn CA. Exposure to alcoholism in the family. J Psychol. 2008; 205:1-13. PMID: 10114780
21. Miller-Tutzauer C, Leonard KE, Windle M. Marriage and alcohol use: a longitudinal study of "maturing out". J Stud Alcohol. 1991 Sep;52(5):434-40. DOI: 10.15288/jsa.1991.52.434
22. Staff J, Schulenberg JE, Maslowsky J, Bachman JG, O'Malley PM, Maggs JL, et al. Substance use changes and social role transitions: proximal developmental effects on ongoing trajectories from late adolescence through early adulthood. Dev Psychopathol. 2010 Nov;22(4):917-32. DOI: https://doi.org/10.1017/S0954579410000544
23. Sawant N, Dave K. Coping with drinking: A study in the wives of alcoholics. Indian J Psychol Med. 2007;29(2):64-7. DOI:10.1177/0975156420070210
24. Kaur S. A descriptive study to assess depression and codependency among wives of alcoholics in a selected rural community of Gurdaspur, Punjab. Asian J NursEduc Res. 2016;6(2):183. DOI: 10.5958/2349-2996.2016.00033.1  
25. McInnis-Perry GJ, Good JM. A psychoeducational codependency support group for older adults who reside in the community: Friends supporting friends. J GerontolNurs. 2006;32(8). DOI: 10.3928/00989134-20060801-06
26. Bhowmick P, Tripathi BM, Jhingan HP, Pandey RM. Social support, coping resources and codependence in spouses of individuals with alcohol and drug dependence. Indian journal of psychiatry. 2001 Jul 1;43(3):219-24. PMCID: PMC2956145
27. Sawane K, Upendra S. Co-dependency and depressive symptoms among wives of alcoholics. J Psychiatr Nurs. 2014;3(2):41-76. [JPN Web Link]
28. Rao TSS, Kuruvilla K. A study on the personality characteristics of wives of alcoholics. Indian J Psychiatry. 1991;33(3):180-6. PMCID: PMC2988305
29. Avila Escribano JJ, Ledesma Jimeno A. [The personality of wives of alcoholic patients]. Actas Luso Esp Neurol Psiquiatr Cienc Afines. 1990;18(6):355-63. PMID: 2094171
30. Orford J, Guthrie S, Nichols P, Oppenheimer E, Egert S, Ilensman C. Self-reported coping behavior of wives of alcoholics and its association with drinking outcome. J Stud Alcohol. 1976; 36:1254-67. DOI: 10.15288/jsa.1975.36.1254
31. Stanley S. Co-dependency: Personality correlates in spouses of alcoholics. Indian J Soc Work. 2004;65(2):213-26. [ResearchGate]
32. Panaghi L, Ahmadabadi Z, Khosravi N, Sadeghi MS, Madanipour A. Living with addicted men and codependency: The moderating effect of personality traits. Addict Health. 2016;8(2):98-106. PMCID: PMC5115643

Funding: Self funded

Conflict of Interest: None

Please cite the article as: Baby A, Chakkalakudy GC, Valsan N, Jose.J. Codependency And Personality Characteristics Of Caregivers Of Patients With Alcohol Dependence Syndrome: A Cross-Sectional Study. Kerala Journal of Psychiatry 2024; xxx:xx.